JP2014520856A - Combined ALS therapy - Google Patents

Abstract

Provided is a method of treating ALS in a subject comprising administering to the subject a therapeutically effective amount of riluzole and a therapeutically effective amount of CK-2017357. Further, a method of reducing variability in riluzole exposure (eg, Cmax and / or AUC24h) in a subject, variability in riluzole exposure (eg, Cmax and / or AUC24h) between two or more subjects. Methods for reducing, methods for reducing the total daily dose of riluzole in a subject, methods for extending the half-life of riluzole in a subject, methods for reducing the number of doses of riluzole in a subject, and subjects being treated with riluzole Also provided are methods for reducing the occurrence and / or severity of adverse events in the body.

Description

(Cross-reference to related applications)
This application is filed with US Provisional Patent Application No. 61 / 507,381 filed on July 13, 2011, US Provisional Patent Application No. 61 / 637,770 filed on April 24, 2012, October 2010. US Provisional Patent Application No. 61 / 544,533, filed on May 7, US Provisional Patent Application No. 61 / 646,699, filed May 14, 2012, and filed on April 24, 2012 Claiming the benefit of priority to published US Provisional Patent Application No. 61 / 637,759, each of which is incorporated herein by reference for all purposes.

  Amyotrophic lateral sclerosis (ALS) is a degenerative and progressive disorder of the nervous system. ALS is characterized by progressive damage to motor neurons in the lateral cords of the spinal cord and / or motor cortex. With progressive damage to motor neurons, innervation to skeletal muscle is lost, which prevents walking and daily life, affecting swallowing and breathing. ALS is a rare disease, usually a fatal disease. The progression can vary, but in the average patient, death occurs within 3 years of diagnosis. Most patients die from respiratory failure due to bronchitis and pneumonia as the main cause of death. Since there is no therapeutic treatment, the treatment is supportive.

  Riluzole is currently the only drug approved for treating ALS. Although the exact mechanism of action of riluzole is unknown, it is believed to act by inhibiting the adverse effects of glutamate and other neurotransmitter overloads in the central nervous system (eg, Curatier et al., NeuroReport ( (1994), 5 (8), 1012-14, Estevez et al., Eur. J. Pharmacol. (1995), 280 (1), 47-53, Rothstein et al., J. Neochem. 1995), 65 (2), 643-51). Studies have shown that serum and plasma concentrations of riluzole vary considerably from person to person (see, eg, Groeneveld et al., J. Neurol. Sci. (2001), 191, 310-13). I want to be) Such variability can make it difficult to determine and deliver a therapeutically effective dose to a patient and can affect the occurrence and severity of adverse events (eg, Groeneveld et al., Neurology (2003), 61 Vol. 1141-43).

  6-ethynyl-1- (pentan-3-yl) -1H-imidazo [4,5-b] pyrazin-2 (3H) -one (also known as CK-2017357 or CK-357) is a fast skeleton A selective activator of the fast skeletal muscle troponin complex, which increases the sensitivity of fast skeletal muscle to calcium, amplifies the response to neuromuscular input, improves muscle strength, and muscles (See, for example, US Pat. No. 7,598,248). The use of CK-2017357 has been studied for use in the treatment of ALS patients. By increasing the contractile force developed by fast skeletal muscle fibers in response to any level of neural input, treatment with CK-2017357 improves daily activities (such as walking, breathing and eating) and reduces hospitalization. And possibly prolong the survival of ALS patients.

CK-2017357 is, _{K I} (inactivation constant) of 1.9μM and 0.031min having ^-1 _{k inact} (maximum rate constant of inactivation), inhibitors based on the mechanism of human CYP1A2 in in vitro It is shown that. In humans, riluzole is metabolized primarily by CYP1A2 (see, eg, Sanderink et al., J. Pharmacol. & Exp. Ther. (1997), 282 (3), 1465-72). Many other drugs have been evaluated for their ability to inhibit riluzole metabolism by human liver microsomes in vitro, but in some cases (eg, amitriptyline, diclofenac, diazepam, nicergoline, clomipramine, imipramine) observed inhibition However, since high concentrations are required for inhibition, these drugs are unlikely to change riluzole concentrations when used in combination with riluzole in clinical settings (Non-Patent Document 1).

Bensimon et al., Expert Opin. Drug Saf. (2004), Volume 3 (6), 525-34

  Provided is a method of treating ALS in a subject comprising administering to the subject a therapeutically effective amount of riluzole and a therapeutically effective amount of CK-2017357.

Further provided is a method of reducing fluctuations in riluzole exposure (eg, C _max and / or AUC _24h ) in the subject, comprising administering to the subject a therapeutically effective amount of CK-2017357.

Further, variation in riluzole exposure (eg, C _max and / or AUC _24h ) between the subjects, comprising administering a therapeutically effective amount of CK-2017357 to two or more subjects. A method for reducing the size is also provided.

Further provided is a method of increasing riluzole exposure (eg, C _max and / or AUC _24h ) in said subject, comprising administering to the subject a therapeutically effective amount of CK-2017357.

  Further provided is a method of extending the half-life of riluzole in the subject comprising administering to the subject a therapeutically effective amount of CK-2017357.

  Further provided is a method of reducing the frequency of riluzole administration in the subject, comprising administering to the subject a therapeutically effective amount of CK-2017357.

  Further provided is a method of reducing the total daily dose of riluzole in the subject, comprising administering to the subject a therapeutically effective amount of CK-2017357.

  Further provided is a method of reducing the occurrence and / or severity of adverse events in a subject treated with riluzole, comprising administering to the subject treated with riluzole a therapeutically effective amount of CK-2017357. The

  Further provided are pharmaceutical compositions comprising a therapeutically effective amount of riluzole and a therapeutically effective amount of CK-2017357.

  Further provided is a method for treating ALS in a subject comprising administering to the subject CK-2017357 at a dose of at least twice daily.

FIG. 1 shows the average riluzole plasma concentration as a function of time for riluzole alone (single dose 50 mg) and riluzole (single dose 50 mg) and CK-2017357 (daily 250 mg × 11 days) in healthy subjects. Present. FIG. 2 illustrates the effect of steady state CK-2017357 on riluzole pharmacokinetics in healthy subjects. Panel A presents the C _max for riluzole alone (single dose 50 mg) and riluzole (single dose 50 mg) + CK-2017357 (11 days, 250 mg daily). Panel B presents AUC _inf for riluzole alone (single dose 50 mg) and riluzole (single dose 50 mg) + CK-2017357 (250 mg daily for 11 days). The figure shows that in healthy subjects, intersubject variation in riluzole C _max was reduced by co-administration with CK-2017357. FIG. 3 presents the average riluzole plasma concentration as a function of time for ALS patients with 50 mg riluzole administered with BID and either 250 mg or 500 mg CK-2017357 administered in a single dose. FIG. 4 shows a test flow diagram for a clinical trial examining a CK-20173571 twice daily dose titration regimen in ALS patients.

  As used herein, the following abbreviations, words, and phrases are generally intended to have the meanings set forth below, unless the context in which they are used otherwise.

As used herein, AUC _24h is the area under the plasma concentration-time curve from time 0 to the final measurable plasma concentration (eg, 24 hours) calculated by the linear trapezoidal formula. That is.

  As used herein, ALS or amyotrophic lateral sclerosis refers to a motor neuron disease commonly known as Lou Gehrig's disease, and in some embodiments amyotrophic with early medullary involvement. It refers to lateral sclerosis, ie the medullary form of the disease, and in some embodiments, the “limb-onset” type ALS.

  As used herein, QD refers to once a day.

  As used herein, BID refers to twice a day.

As used herein, C _max refers to the maximum plasma concentration.

  As used herein, fm refers to the rate metabolized.

  There is provided a method of treating ALS in a subject comprising administering to the subject a therapeutically effective amount of riluzole and a therapeutically effective amount of CK-2017357.

  In some embodiments, administration of riluzole in combination with CK-2017357 prolongs survival and / or time to tracheostomy.

  In some embodiments, the therapeutically effective amount of riluzole administered in combination with CK-2017357 is lower than the therapeutically effective amount when riluzole is administered alone (ie, without CK-2017357 treatment). In some embodiments, both a therapeutically effective amount of riluzole and a therapeutically effective amount of CK-2017357, when administered in combination, are therapeutically effective amounts of riluzole and CK-201735 when each is administered alone. The dose is less than the effective amount.

  In some embodiments, the administration of riluzole is BID. In some embodiments, the administration of riluzole is QD.

  In some embodiments, the administration of CK-2017357 is BID. In some embodiments, the administration is QD.

  In some embodiments, the administration of riluzole is QD and the administration of CK-2017357 is BID. In some embodiments, the administration of riluzole is BID and the administration of CK-2017357 is BID.

  In some embodiments, the administration of riluzole is QD and the administration of CK-2017357 is QD. In some embodiments, the administration of riluzole is BID and the administration of CK-2017357 is QD.

  In some embodiments, CK-2017357 is administered at two or more doses at different times (eg, once in the morning and once in the evening). In some embodiments, CK-2017357 is administered at the same dose twice or more than twice. In some embodiments, CK-2017357 is administered at two or more different doses. In some embodiments, the dose of CK-2107357 is adjusted over time to different daily dose levels (eg, higher amounts).

  In some embodiments, a single daily dose of 50 mg riluzole is administered in combination with a therapeutically effective amount of CK-2017357. In some embodiments, a single daily dose of 50 mg riluzole is administered in combination with a total daily dose between about 125 mg and 2000 mg of CK-2017357. In some embodiments, a single daily dose of 50 mg riluzole is administered in combination with a total daily dose of 125 mg, 250 mg, 375 mg or 500 mg of CK-2017357.

  In some embodiments, a twice daily dose of 25 mg riluzole is administered in combination with a therapeutically effective amount of CK-2017357. In some embodiments, a twice daily dose of 25 mg riluzole is administered in combination with a total daily dose of between about 125 mg and 2000 mg of CK-2017357. In some embodiments, a twice daily dose of 25 mg riluzole is administered in combination with a total daily dose of 125 mg, 250 mg, 375 mg or 500 mg of CK-2017357.

  In some embodiments, a single daily dose of 25 mg riluzole is administered in combination with a therapeutically effective amount of CK-2017357. In some embodiments, a single daily dose of 25 mg riluzole is administered in combination with a total daily dose between about 125 mg and 2000 mg of CK-2017357. In some embodiments, a single daily dose of 25 mg riluzole is administered in combination with a total daily dose of 125 mg, 250 mg, 375 mg or 500 mg of CK-2017357.

  In some embodiments, a twice daily dose of 12.5 mg riluzole is administered in combination with a therapeutically effective amount of CK-2017357. In some embodiments, a twice daily dose of 12.5 mg riluzole is administered in combination with a total daily dose of between about 125 mg and 2000 mg of CK-2017357. In some embodiments, a twice daily dose of 12.5 mg riluzole is administered in combination with 125 mg, 250 mg, 375 mg or 500 mg of CK-2017357.

  Further disclosed is a method of extending the half-life of riluzole in a subject comprising administering to the subject a therapeutically effective amount of CK-2017357.

  Further, in a subject, the frequency of administration of riluzole is reduced (eg, twice a day to once a day) or the dose of riluzole administered to a subject is reduced (eg, 200 mg to 1 day per day). 100 mg, or 100 mg per day to 50 mg per day, or 50 mg per day to 25 mg per day) are also disclosed.

In addition, subjects with riluzole exposure (eg, C _max and / or AUC _24h ) between the subjects, comprising administering a therapeutically effective amount of CK-2017357 to two or more subjects. A method for reducing inter-period variation is also disclosed.

Further disclosed is a method of reducing the in-subject variation of riluzole exposure (eg, C _max and / or AUC _24h ) comprising administering to the subject a therapeutically effective amount of CK-2017357.

  Further disclosed is a method of reducing the occurrence and / or severity of an adverse event in a subject comprising administering to the subject treated with riluzole a therapeutically effective amount of CK-2017357. In some embodiments, the adverse event is a CNS-related adverse event (see, eg, Mashiro et al., Anthesia & Analgesia (2007), 104, 1415-21).

  In some embodiments, CK-2017357 is administered to a subject in combination with riluzole administration, ie CK-2017357 and riluzole are administered simultaneously, essentially simultaneously, or within the same treatment protocol. . In some examples of concurrent administration, administration of CK-2017357 and riluzole begins at the same time and ends at the same time (ie, on the same day or within the same treatment protocol). In other examples of co-administration, only one of CK-2017357 and riluzole is administered during the first period, and then CK-2017357 and riluzole are co-administered during the second period. The For example, the subject receives riluzole in a first period and then receives both CK-2017357 and riluzole in a second period. Thereafter, administration of either CK-2017357 or riluzole may be continued for a third period. In another example, a subject may receive CK-2017357 during a first period and then receive both CK-2017357 and riluzole during a second period. Thereafter, administration of either CK-2017357 or riluzole may be continued for a third period. In other examples of co-administration, CK-2017357 and riluzole are co-administered during the first period, and then only one of CK-2017357 and riluzole is administered during the second period. For example, a subject may receive both CK-2017357 and riluzole in a first period and then receive CK-2017357 in a second period. In another example, a subject may receive both CK-2017357 and riluzole in a first period and then receive riluzole in a second period. In all instances, alternate administration may be repeated during a single treatment protocol. Determination of the order of administration during the treatment protocol and the number of repetitions of each treatment is within the knowledge of one skilled in the art after assessing the patient's condition.

  In some embodiments, riluzole and CK-2017357 are administered sequentially. In some examples of sequential administration, CK-2017357 is administered to the subject after completion of riluzole administration. Administration of CK-2017357 may begin immediately after the end of riluzole administration, or between the end of riluzole administration and the start of CK-2017357 administration (eg, 1 day, 1 week, 1 month) , 6 months, 1 year, etc.). In another example of sequential administration, riluzole is administered to the subject after administration of CK-2017357 is complete. Riluzole administration may begin immediately after the end of CK-2017357 administration, or between the end of CK-2017357 administration and the start of riluzole administration (eg, 1 day, 1 week, 1 month) , 6 months, 1 year, etc.). In each instance, alternate administration may be repeated during a single treatment protocol. The determination of the order of administration during the treatment protocol and the number of repetitions of each treatment is within the knowledge of one of ordinary skill in the art after assessing the patient's condition.

  In some embodiments, CK-2017357 and riluzole are administered in a single pharmaceutical composition. Single pharmaceutical compositions include, but are not limited to, oral, sublingual, subcutaneous, intravenous, intranasal, topical, transdermal, intraperitoneal, intramuscular, intrapulmonary, vaginal, rectal or intraocular, Administration can be by any of the accepted modes of administration of therapeutic agents. In some embodiments, a single pharmaceutical composition is administered orally. In some embodiments, a single pharmaceutical composition is formulated to administer both CK-2017357 and riluzole at the same time or rate. In some embodiments, a single pharmaceutical composition is formulated to administer both CK-2017357 and riluzole at different times or rates. For example, a single pharmaceutical composition may deliver riluzole at a slower rate than CK-2017357, or CK-2017357 at a slower rate than riluzole. In another example, a single pharmaceutical composition may initially deliver CK-2017357 followed by riluzole (ie, delayed release of riluzole) or initially deliver riluzole followed by CK-2017357 ( That is, CK-2017357 may be delayed released).

  In some embodiments, CK-2017357 and riluzole are administered in separate pharmaceutical compositions. Each agent may be administered by a different route due to different physical and chemical properties. For example, one drug can be administered orally while the other is administered intravenously. Alternatively, each agent may be administered by the same route. For example, both CK-2017357 and riluzole may be administered orally (ie, in the form of two separate pills or capsules). It is within the knowledge of those skilled in the art to determine the mode of administration and whether or not to administer it in the same pharmaceutical composition (if possible). Initial administration can be done by established protocols known in the art, and then the dosage, mode of administration, and administration time can be modified by those skilled in the art based on the observed effects.

  Further provided is a method of treating ALS by administering to a patient at least twice a daily dose of CK-2017357. In some embodiments, two doses of CK-2017357 are administered at different times (eg, once in the morning and once in the evening). In some embodiments, the total daily dose is at least about 250 mg, or at least about 300 mg, or at least about 350 mg, or at least about 400 mg, or at least about 450 mg, or at least about 500 mg. In some embodiments, at least one of the doses is equal to or greater than about 125 mg, or equal to or greater than about 150 mg, or equal to or greater than about 200 mg, or Equal to or greater than about 250 mg. In some embodiments, at least two of the doses are equal to or greater than about 125 mg, or equal to or greater than about 150 mg, or equal to or greater than about 200 mg, or Is it equal to or greater than about 250 mg? In some embodiments, CK-2017357 is administered two or more times at the same dose (eg, twice at the same dose 125 mg, or twice at the same dose 250 mg). In some embodiments, CK-2017357 is administered at two or more different doses (eg, 125 mg / 250 mg, or 250 mg / 125 mg). In some embodiments, the dose of CK-2107357 is adjusted over time to different daily dose levels (eg, higher amounts).

  CK-2017357 is a therapeutic agent including, but not limited to, oral, sublingual, subcutaneous, intravenous, intranasal, topical, transdermal, intraperitoneal, intramuscular, intrapulmonary, vaginal, rectal or intraocular Can be administered by any of the accepted modes of administration. In some embodiments, CK-2017357 is administered orally. In other embodiments, CK-2017357 is administered intravenously. In yet other embodiments, CK-2017357 is administered to the lung by inhalation or spraying of dry powder, suspension, solution or aerosol containing CK-2017357.

  Pharmaceutically acceptable compositions include, for example, solid, semi-solid, liquid and aerosol dosage forms such as tablets, capsules, powders, liquids, suspensions, suppositories, aerosols and the like. . CK-2017357 is also a sustained or sustained release dosage form (accumulation injection, osmotic pump, pills, transdermal) for sustained and / or timed pulsing at a predetermined rate. (Including patches (including electrotransport)). In certain embodiments, the composition is provided in unit dosage forms suitable for single administration of precise dosages.

  CK-2017357 can be used alone or as a conventional pharmaceutical carrier, excipient, etc. (eg, mannitol, lactose, starch, magnesium stearate, sodium saccharin, talc, cellulose, croscarmellose sodium, glucose, gelatin, Sucrose, magnesium carbonate, etc.). If desired, the pharmaceutical composition may comprise a wetting agent, an emulsifier, a solubilizer, a pH buffer, etc. (eg, sodium acetate, sodium citrate, cyclodextrin derivatives, sorbitan monolaurate, triethanolamine acetate, oleic acid Small amounts of non-toxic auxiliary substances such as triethanolamine may also be included. Generally, depending on the intended mode of administration, the pharmaceutical composition will contain about 0.005% to 95% by weight, or in some embodiments about 0.5% to 50%, by weight CK-2017357. Would. Actual methods of preparing such dosage forms are known, or will be apparent to those skilled in the art. See, for example, Remington's Pharmaceutical Sciences, Mack Publishing Company, Easton, Pennsylvania.

  In certain embodiments, the composition will take the form of a pill or tablet, so that the composition, together with the active ingredient, is a diluent such as lactose, sucrose, dicalcium phosphate, Lubricants such as magnesium stearate and binders such as starch, acacia gum, polyvinylpyrrolidine, gelatin, cellulose, cellulose derivatives may be included. In certain embodiments of solid dosage forms, powders, granules, solutions, or suspensions (eg, in propylene carbonate, vegetable oils or triglycerides) are encapsulated in gelatin capsules.

  Pharmaceutically administrable liquid compositions are, for example, dispersed in a carrier (eg, water, saline, aqueous dextrose, glycerol, glycol, ethanol, etc.), which dissolves the active ingredient and optional pharmaceutical adjuvants. Or the like to form a solution or suspension. Injectables can be prepared in conventional forms, either as liquid solutions or suspensions as emulsions, or in solid forms suitable for solution or suspension in liquid prior to injection. The proportion of CK-2017357 contained in such parenteral compositions depends on the particular nature of the compound, as well as the activity of CK-2017357 and the needs of the subject. In some embodiments, a proportion of 0.01% to 10% of the active ingredient in solution can be used, and this proportion is when the composition is a solid (the composition is later diluted). Get higher.

  The pharmaceutical composition of CK-2017357 may also be administered to the respiratory tract alone or in combination with an inert carrier such as lactose as an aerosol or liquid for nebulizers or as a fine powder for insufflation. In some embodiments, the particles of the pharmaceutical composition have a diameter of less than 50 microns, and in some embodiments, have a diameter of less than 10 microns.

Example 1 Effect of multiple daily doses of CK-2017357 on single dose PK of riluzole in healthy subjects The main purpose of this study was to determine the single dose of riluzole in healthy subjects. It was to evaluate the effect of multiple daily doses of CK-2017357 on pharmacokinetics (PK). On day 1, 12 subjects (7 men and 5 women) received a single oral dose of 50 mg riluzole. On day 6, all subjects began taking oral 250 mg CK-2017357 on QD for 11 days (up to day 16). On day 13, 11 of 12 subjects received another single oral dose of 50 mg riluzole. Each dose of riluzole is followed by plasma before administration, 0.5, 1, 1.5, 2, 3, 4, 6, 8, 12, 16, 24, 36, 48, 72 and 96 hours after administration. A sample was taken. The plasma concentration of riluzole was determined using a validated HPLC / MS / MS method with a quantitative range of 5.00 to 2,000 ng / mL. Samples were analyzed by using an aliquot volume of 50.0 μL and a protein precipitation extraction procedure followed by HPLC / MS / MS. Riluzole concentrations riluzole as internal standard ^- 13 using ^C, 15 _{N 2,} over a concentration range of 5.00～2,000 was calculated by 1 / ^{x 2} linear regression. Separately, another set of plasma samples was collected before administration of CK-2017357 on days 11, 12, and 13. These plasma samples were analyzed for CK-2017357 trough levels using a validated LC / MS / MS method to determine CK-2017357 steady state pharmacokinetics.

  Riluzole plasma concentration data were analyzed by non-compartmental methods to determine riluzole pharmacokinetic parameters. Descriptive pharmacokinetic parameters such as Cmax, Tmax, AUC, t1 / 2, Cl / F, and V / F were calculated using Phoenix WinNonlin 6.1 (Pharsight, Mountain View, CA). For the calculation of descriptive statistics and non-compartmental analysis, all concentrations with <LLOQ were set to zero. A summary of the riluzole PK parameters is shown in Tables 1A and 1B below.

  Table 1A: Summary of Riluzole Pharmacokinetic Parameters in Healthy Subjects

Table 1B: Summary of pharmacokinetic parameters of riluzole + CK2017357 (250 mg QD) in healthy subjects

The degree of drug-drug interaction was evaluated by comparing the AUC _inf value from period 1 (riluzole alone) with the value from period 2 (riluzole + CK-2017357). The results of this test are shown in Table 2 below. The mean plasma concentration-time profile is shown graphically in FIG. 1 and the C _max and AUC _inf data for period 1 and period 2 are shown in FIG.

Table 2: Individual fold increase and summary of riluzole AUC _inf in the presence of steady state CK-2015375 (250 mg) in healthy subjects

This study shows that steady-state CK-2017357 (250 mg) increases the average C _{max of} riluzole by about 1.7 times and the average AUC _inf by about 4.4 times compared to riluzole alone. showed that. The average t _1/2 of riluzole extended from 8.0 hours to 15.5 hours in the presence of steady state CK-2017357. As illustrated in FIG. 2, in these healthy subjects, co-administration of CK-2017357 generally reduced intersubject variability in riluzole pharmacokinetics.

Example 2 Drug-Drug Interaction (DDI) between Riluzole and CK-2017357 in ALS Patients
This was a three-period crossover test with placebo as a control. Each patient received BID 50 mg riluzole and a single dose of placebo, 250 mg CK-2017357, and 500 mg CK-2017357, in random order, 6-10 days apart. In this clinical trial, duplicate PK samples were taken from each patient. The first set was analyzed for CK-2017357 using a validated LC / MS / MS method and the other set was analyzed for riluzole. Riluzole exposure (AUC _24h ) was calculated for each patient and for each treatment of CK-2015357 (placebo, 250 mg and 500 mg). The degree of drug interaction was assessed using the fold increase in riluzole AUC over the placebo period of CK-2017357.

The plasma concentration of riluzole was determined using a validated HPLC / MS / MS method with a quantitative range of 5.00 to 2,000 ng / mL. Samples were analyzed by using an aliquot volume of 50.0 μL and a protein precipitation extraction procedure followed by HPLC / MS / MS. Riluzole concentrations riluzole as internal standard ^- 13 using ^C, 15 _{N 2,} over a concentration range of 5.00～2,000 was calculated by 1 / ^{x 2} linear regression. Descriptive pharmacokinetic parameters such as _Cmax , _Tmax , AUC, t1 _{/ 2} , Cl / F and V / F were calculated using Phoenix WinNonlin 6.1 (Pharsight, Mountain View, CA). For the calculation of descriptive statistics and non-compartmental analysis, all concentrations with <LLOQ were set to zero. Since the administration time for riluzole was not recorded, the elapsed time was calculated based on the nominal time point of CK-2017357, and this time was used to calculate AUC _24h for riluzole.

  The results of this experiment are summarized in Table 3 below, and the mean plasma concentration-time profile is shown in FIG.

Table 3: _{ALU 24h} and AUC _24hr fold increase of individual riluzole after 50 mg oral riluzole twice _daily and their summary

Analysis of AUC _24h for riluzole after 50 mg with BID showed a general trend of increasing riluzole concentration during the CK-2017357 active period (250 mg and 500 mg vs. 0 mg). Compared to the placebo period of CK-2017357, the average AUC _24h for riluzole was increased about 2.1-fold and 2.6-fold for CK-2017357 at 250 mg and 500 mg doses, respectively. As illustrated in FIG. 3, the average C _max of riluzole almost doubled in the presence of a steady state concentration of CK-2017357.

Example 3 Pharmacokinetics and Interactive Effects of Fast Skeletal Muscle Activator CK-2017357 and Riluzole The purpose of this study was to determine the repeated dose of CK-2017357 in both the presence and absence of riluzole. It was to determine the kinetics and the effect of varying doses of CK-2017357 on serum levels of plasma riluzole.

  In this study, 49 ALS patients were treated. Twenty-four patients did not take riluzole, and the rest took a fixed but small amount of riluzole (50 mg daily). Patients (n = non-riluzole / taker) received a single daily placebo (n = 6/7), 125 mg, 250 mg or 375 mg of CK-357 (n = 6 for all three CK-2017357 groups) / 6) received 14 days of administration. Levels of CK-2017357 and riluzole were measured on days 1, 2, 8, and 15.

Plasma levels of CK-2017357 that reached steady state by day 8, ie, 4 hours after administration on day 8, were about 70% higher than 4 hours after the first administration on day 1. As presented in Table 4, the C _{max of} CK-2017357 increased proportionally with dose without the apparent effect of riluzole.

Table 4: CK-2017357C _max level with and without riluzole

As shown in Table 5 below, CK-2017357 doubled riluzole levels across all dose groups. The frequency of adverse events did not vary with the presence of riluzole at any dose of CK-2017357.

Table 5: Riluzole C _max levels in the presence of various doses of CK-2017357

CK-2017357 has a predictable linear rate of repeated doses used in this study and reaches steady state within a week. Plasma levels of CK-2017357 were not affected by the presence of riluzole. Riluzole levels were increased by CK-2017357 and plasma levels increased almost 2-fold across all dose levels of CK-2017357. However, while reducing the daily dose of riluzole to 50 mg, no adverse events due to higher riluzole levels were reported during the study. These results suggest that CK-2017357 and riluzole can be safely administered in combination.

(Example 4) Examination of CK-20173571 twice daily dose escalation regimen in ALS patients Prior to clinical experiments, 1- (ethylpropyl) -6-ethynylimidazo [4,5-b] pyrazin-2-ol ( CK-2017357) was administered once a day in the morning. In these studies, overall evaluation by patients and investigators, muscle fatigue, and improved lung function were observed, but dizziness was a dose-limited adverse event in both healthy volunteers and ALS patients. It was. This example can increase the tolerable daily maximum total dose of CK-2017357 by dividing the daily dose into two doses (morning and evening) and start treatment at a lower dose And increasing the dosage to a target dose of 250 mg twice daily.

  Patients enrolled in this clinical trial were randomized, double-blind, with placebo as a control. For riluzole, there was a 7 day stabilization period at doses as low as 50 mg in QD. Thereafter, the patients were randomized 3: 1 for 14 days of CK-2017357 or placebo.

  The dose escalation method for CK-2017357 was as follows. Administration was started at 125 mg twice daily (total daily dose of 250 mg) for 7 days, and increased to 125 mg in the morning and 250 mg in the evening on day 8 (total daily dose of 375 mg), and 250 mg twice daily on day 15 The dose was adjusted (total daily dose 500 mg) until the morning of the 22nd day. Patients who could not tolerate dose escalation returned to the previous tolerated dose level and remained at that dose level and completed the study. Placebo patients received a dummy similar dose adjustment and remained blind. FIG. 4 illustrates this test design.

  Twenty-seven patients were treated in this study. All six patients randomized to placebo completed taking 3 weeks. Of the 21 patients randomly classified for treatment with CK-2017357, 14 were increased to the highest daily total dose of 500 mg and completed their 3-week dosing. The most commonly reported adverse event caused by treatment is dizziness, which is mild in 10 of the 12 patients where it occurred and moderate in the other 2 It wasn't too much. Vertigo was self-limiting in 6 of the 12 patients where it occurred. A promising increase in ALSFRS-R score and MVV was observed for CK-2017357 compared to placebo. Thus, this study suggests that CK-2017357, administered in a dose escalation method twice daily, is safe and well tolerated.

  Although the invention has been described with reference to the specific embodiments described herein, various modifications can be made and equivalents without departing from the true spirit and scope of the invention. It should be understood by those skilled in the art that they can be replaced. In addition, modifications may be made to accommodate a particular situation, material, material composition, and / or purpose, spirit and scope of the invention. All such modifications are intended to be within the scope of the claims appended hereto.

Claims (26)

A method of treating ALS in a subject, comprising administering to the subject a therapeutically effective amount of riluzole and a therapeutically effective amount of CK-2017357. The method of claim 1, wherein the therapeutically effective amount of riluzole administered in combination with CK-2017357 is a dose that is less than the therapeutically effective amount of riluzole when administered alone. A method of reducing variation in riluzole exposure in a subject comprising administering to the subject a therapeutically effective amount of CK-2017357. A method of reducing the total daily dose of riluzole in a subject, comprising administering to the subject a therapeutically effective amount of CK-2017357. A method of extending the half-life of riluzole in a subject, comprising administering to the subject a therapeutically effective amount of CK-2017357. A method of reducing the frequency of administration of riluzole in a subject, comprising administering to the subject a therapeutically effective amount of CK-2017357. The method according to claim 6, wherein the frequency of administration of riluzole is changed from twice or more than once per day to once per day. A method of reducing the occurrence and severity of adverse events in a subject treated with riluzole, comprising administering to the subject a therapeutically effective amount of CK-2017357.   9. The method of claim 8, wherein the adverse event is a CNS related adverse event.   10. The method according to any one of claims 1 to 9, wherein the riluzole is administered QD.   12. The method of claim 10, wherein the CK-2017357 is administered QD.   11. The method of claim 10, wherein the CK-2017357 is administered with BID.   10. The method according to any one of claims 1 to 9, wherein the riluzole is administered with BID.   14. The method of claim 13, wherein the CK-2017357 is administered QD.   14. The method of claim 13, wherein the CK-2017357 is administered with BID.   16. The method according to any one of claims 1 to 15, wherein the total daily dose of riluzole is selected from 25 mg to 50 mg.   16. The method according to any one of claims 1 to 15, wherein the total daily dose of CK-2017357 is selected from 125 mg, 250 mg, 375 mg and 500 mg.   18. The method according to any one of claims 1 to 17, wherein the riluzole is administered orally.   The method of any one of claims 1 to 18, wherein the CK-2017357 is administered orally.   20. The method according to any one of claims 1 to 19, wherein the riluzole and the CK-2017357 are administered in separate pharmaceutical compositions.   20. The method of any one of claims 1 to 19, wherein the riluzole and the CK-2017357 are administered in a single pharmaceutical composition.   A pharmaceutical composition comprising a therapeutically effective amount of riluzole and a therapeutically effective amount of CK-2017357. A method of treating amyotrophic lateral sclerosis in a patient comprising administering to said patient a dose of CK-2017357 of at least twice daily.   24. The method of claim 23, wherein the total daily dose is at least about 250 mg.   24. The method of claim 23, wherein at least one of the doses is equal to or greater than about 250 mg.   26. The method of claim 25, wherein at least two of the doses are equal to or greater than about 250 mg.